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HILL COUNTY COMMUNITY HEALTH NEEDS ASSESSMENT REPORT
NORTH CENTRAL MONTANA HEALTHY COMMUNITIES
“BUILDING HEALTHY COMMUNITIES”
I. INTRODUCTION
1.1 The Community We Serve
Hill County has a population of 16,096 (2010 Census) and consists of about 2,916 square miles of
land and water. Neighboring counties are Liberty County to the west, Blaine County to the East,
Chouteau County to the south, and the provinces of Alberta and Saskatchewan to the north. Havre,
population 9,310, is the county seat. Other communities include Box Elder, Gildford, Hingham,
Kremlin, Inverness, Rocky Boy, and Rudyard. Hill County contains Beaver Creek Park which is the
largest county park in the nation. The Rocky Boy Indian Reservation is located in Hill and Chouteau
Counties.
Northern Montana Hospital, located in Havre, is the only hospital in Hill County. The hospital has 49
beds. The Northern Montana hospital system includes two medical clinics and a vision center. Some
of the services the campus offers include an emergency room, hospice, birth center, cardiopulmonary rehabilitation, day surgery, dialysis, and a sleep center. Also located on the campus is the
Northern Montana Care Center which provides nursing home and assisted living services. The
Northern Montana Care Center has 136 beds and all rooms are private.
The Hill County Health Department is located in Havre. The Health Department provides many
services to Hill County including immunizations, Public Health Emergency Preparedness, Nurse
Family Partnership, home visiting program, family planning services, and HIV education and testing.
Bullhook Community Health Center is also located in Havre, providing overall health care from
birth to end of life. Bullhook Community Health Center provides preventive care, education,
counseling, case management, urgent and primary care to its patients regardless of their ability to
pay. Dental services are also provided. The Bullhook Community Health Center is a Federally
Qualified Health Center funded in part by the U. S. Department of Health and Human Services to
serve county residents without insurance or who are underinsured.
The Rocky Boy Indian Reservation is home to Tribal Health and Human Services and the Rocky
Boy Clinic. Some of the services offered include primary care, HIV education and testing, prenatal
and newborn services, women’s health care, immunizations, optometry, preventive care, emergency
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services through the tribal emergency medical services team), chemical dependency services,
diabetes education, and a wellness program.
Hill County is a designated a Primary Care Health Professional Shortage Area and Dental Health
Professional Shortage Area as determined by the U.S. Department of Health and Human Services,
Health Resources and Services Administration.
Demographics for Hill County include population age distribution and residential race. Of the 16,096
residents, 30% are under 20 years old and 33% are over 50 years of age.
County residents include 77% Caucasians, 21.7% American Indian, with the remaining to include all
other races.
Population Age Distribution, 2010
Hill County
(Total Population = 16,096)
2038
65 +
3292
50‐64
1868
40‐49
1779
30‐39
2279
20‐29
1231
15‐19
1170
10‐14
2439
Under 10
0
200
400
600
800 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 3,400
Socioeconomic Characteristics have repeatedly shown to have a significant impact on health.
Those with lower socioeconomic status are more likely to engage in high risk behaviors, such as
tobacco use. They are less likely to have adequate health care coverage and less likely to get
preventative health care. Lower socioeconomic status groups are often targeted for public health
interventions. Socioeconomic characteristics for Hill County as compared to Montana overall are
noted below. The areas shaded in green represent positive indicators and those shaded in red are
indicators of concern.
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Socioeconomic Measures
Hill County
Montana
Unemployment Rate
Median Household Income
Percent High School Graduates or GED attainment of the population 25 years or older
Percent of population below Federal Poverty Level
o Children <18
o Adults 18‐64
o Adults 65+
Food Stamp Recipients Marital Status
o Never Maried
o Married
o Widowed
o Divorced
5.3%
$ 46,724
4.5%
$ 43,000
91%
87%
25.7%
16.9%
8.3%
10.0%
19%
13%
9%
8.8%
29%
55%
6%
9%
28%
55%
5%
12%
Source: FactFinder 2010 U.S. Census Data
Of note in these statistics are the higher median household income and graduation rate in Hill County
compared to Montana overall. The number of children under 18 and adults 18 to 64 years of age in
Hill County who are below the Federal Poverty Level is higher than Montana overall, along with the
percentage of food stamp recipients.
1.2 North Central Montana Healthy Communities
A number of non-profit entities in North Central Montana embarked on the development of a
Community Health Needs Assessment. In 2012, some of these entities recognized the need to meet
new IRS requirements under the 2010 Affordable Care Act (non-profit hospitals and health system
entities and Critical Access Hospitals), others wanted to achieve Public Health accreditation (Public
Health Departments), and yet others are required to meet these requirements as federally funded
health centers (Community Health Centers). Many of these entities felt it was the best use of
resources (time, money, expertise, etc.) to band together to work collaboratively in the development
of community health needs assessments as well as a regional, North Central Montana Health Needs
Assessment.
A collaborative group was established in June of 2012, the North Central Montana Healthy
Communities, to develop an approach to developing Community Health Needs Assessments that
would meet each of the partners’ needs. The collaborative partner categories are summarized below
and a detailed list is provided in Appendix A.
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North Central Montana Healthy Communities Partnership Groups Benefis Health System
(5 corporate entities)
Local Health Departments
Montana Public Health Regional Medical Manpower NMHA
Public School Systems
Community
Health Centers
Other Partners (UGF, ORH, Center 4 Mental Health, Gateway, Planned Parenthood, etc.)
Indian Reservations
NMHA = Northcentral Montana Healthcare Alliance
II. APPROACH AND METHODOLOGY
2.1 Community Health Needs Assessment Background
In 2010, congress enacted the Patient Protection and Affordable Care Act (The Affordable Care Act)
which established comprehensive health insurance reforms that are aimed at improving the quality of
health care for all American citizens. As a part of the Affordable Care Act, non-profit hospitals are
required to complete a community health needs assessment every three years. In addition, the
Public Health Accreditation Board requires Health Departments to complete a community health
needs assessment every three years. The federally funded Community Health Clinics in North
Central Montana are also required to complete a community health needs assessment. These
entities in North Central Montana have worked together to develop a community health needs
assessment for each of the thirteen communities (counties and health districts) which meet the
specific requirements for their institutions.
Utilizing the findings of each Community Health Needs Assessment, a process involving community
members will be implemented to develop a Community Health Improvement Plan. The objectives of
the Improvement Plan are to (1) Identify and prioritize health needs in the community as a whole and
for diverse populations within the community (e.g., Native Americans, the elderly, women and
children and poverty); (2) Identify and foster interventions to improve health status within the priority
health areas on an ongoing basis; (3) Identify measureable health indicators that will track
improvements in priority health areas; and (4) Coordinate and leverage resources to support the local
community and the North Central Healthy Communities coalition.
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2.2 Community Health Survey
A community health survey was designed based on other model community health surveys, identified
health indicators and the specific interests of the North Central Montana Health Communities
partners. The survey design and analysis leaders were Alicia M. Thompson, Health Director,
Cascade City-County Health Department and Dr. Greg Madson, Academic Dean and Professor of
Sociology at the University of Great Falls. The four page survey consisted of 31 multiple choice
questions (see Appendix B). A sample size of households in each community was determined for
statistical purposes and the survey was sent out in October 2012. An incentive drawing of survey
respondents was conducted for each community. One household in each community was randomly
selected and sent a $100 gift card as an incentive for responding to the survey.
Of the 5,621 identified households in Hill County, 500 households were mailed surveys and 50
households responded to the survey representing 10%. The average age of the respondents was
53.57, with 68% females and 28% males responding. The results of the survey responses are
provided in Section 3.1 of the report.
2.3 Community Needs Index
The Community Needs Index identifies the severity of health disparities for every ZIP code in the US.
The Index has demonstrated a correlation between community need, preventable hospitalizations
and access to care. The Index was created by Catholic Healthcare West (now Dignity Health) and a
nationally recognized consulting firm. The Index aggregates five socioeconomic indicators/barriers to
health care access known to contribute to health disparities. The five indicators/barriers are: income,
education, culture/language, insurance and housing. The Index identifies communities of high need.
The Community Needs Index for Hill County is provided below. More details about the Community
Needs Index are included in Appendix C.
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Source: Dignity Health, 2012
Zip codes 59501 and 59521 are identified as having the highest community need with Zip code 59530
is classified as lowest community need.
2.4 County, State and National Data Sources
When available, the most current data was used to determine the health needs of the community. A
particularly valuable data resource was the Montana Department of Public Health and Human
Services (DPHHS): Community Health Assessment data set by County, when available. Region 2 –
North Central Montana counties combined was used when county-specific data was not available.
Other DPHHS data (e.g. Montana Cancer Registry Report, Mortality Data, etc.). For socioeconomic
and demographic data, the American FactFinder data base was utilized which is based on the U.S.
Census 2010.
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III. FINDINGS
3.1 Community Health Survey
The Hill county survey respondents were asked if they thought their county was healthy. Thirty
percent of the respondents agreed that Hill County was healthy, with 42% disagreeing with that
statement. Of note was that 22% of the survey respondents had no opinion as to whether their
community was healthy or not.
Hill County Is Your Community Healthy?
6% Did Not Answer Question
30% Agree/Strongly Agree
42% Disagree
22% No Opinion
The Hill County respondents identified what they perceived as the ten most serious health concerns
which are shown below. The county responses were also compared with the North Central Montana
region. As shown, Hill County respondents identified alcohol abuse as the most serious health
concern, followed by cancer, illegal drug abuse, overweight and obesity, and dental care.
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Hill County
Top 10 Most Serious Health Concerns
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Hill County (n = 50)
NC MT (N = 729)
When asked “What are the most critical characteristics of a healthy community?” the respondents
noted the importance of good paying jobs and religious or spiritual values. Access to health care, a
strong family life, and safe neighborhoods were tied for third most important aspects of a healthy
community.
Most Important Aspects of a Healthy Community
Hill County
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Hill County (n = 50)
NC MT (N = 729)
Good paying job Religious or Access to health Strong family life
Safe opportunities spiritual values care and other neighborhoods
services 8
3.2 Health Risk Behaviors
Some of the most important determinants of overall health are behavioral. Risk of developing many
chronic diseases or communicable diseases, as well as injuries, can be reduced by changing
personal behavior. The indicators below correlate with information found in the Behavioral Risk
Factor Surveillance System (BRFSS) a self-reported survey. Specific information from Hill County is
shown below.
Source: Montana Department of Public Health and Human Services
Tobacco use is significantly higher for Hill county compared to Montana overall. Binge drinking is
also higher for Hill County.
Hill County survey respondents were asked “What are the lifestyle choices in your community that
concern you most?” Drinking and driving, illegal drug use, and alcohol abuse were the top three
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concerns for the county. Prescription drug abuse and dropping out of school is much more of a
concern for Hill County residents compared to Montana overall.
Lifestyle Choices in Your Community That Concern You Most
Hill County
60%
50%
40%
30%
Hill County (n = 50)
20%
NC MT (N = 729)
10%
0%
Drinking and driving Illegal drug use Alcohol abuse Overweight and Prescription drug Dropping out of obesity abuse
school
Lifestyle also contributes to behavioral risk factors. Lifestyle behavioral risk factors for Region 2 as
compared to Montana overall are noted below.
Source: Montana Department of Public Health and Human Services
Lifestyle risk behaviors are all higher for Region 2 residents than Montana overall, with No Leisure
Time Physical Activity and Obesity being significantly higher than Montana overall.
3.3 Mortality
Understanding the mortality rate and associated causes of death is an important aspect of a
community health assessment. The following table provides reported information regarding mortality
in Hill County compared to Montana overall.
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Source: Montana Department of Public Health and Human Services
The pneumonia/influenza mortality rate and the unintentional injury death rate are both higher in Hill
County than Montana overall. The drug related mortality rate is also higher in Hill County than
Montana overall. The mortality rates for diabetes and chronic liver disease are significantly higher in
Hill County than Montana overall.
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3.4 Disease Incidence and Prevalence
3.4.1 Cancer
Cancer screening for certain cancers is very critical for detecting cancer at an early stage of disease
which increases the chance for successful treatment and/or cure. The indicators below correlate with
information found in the Behavioral Risk Factor Surveillance System (BRFSS) a self-reported survey.
Specific information from Hill County is not available, however, Region 2, Northcentral Montana, data
is shown in the table below. Region 2 includes: Glacier, Toole, Liberty, Hill, Blaine, Pondera, Teton,
Chouteau, and Cascade counties.
Source: Montana Department of Public Health and Human Services
Region 2 reported a slightly higher Pap test and a significantly higher mammogram rate than
Montana overall. However the region had a significantly lower Blood Stool Test rate than Montana
overall.
Cancer incidence as reported by the Montana Cancer Registry lists the cancer incidence rates for all
cancer sites as well as four of most prevalent cancer rates in Region 2 – Northcentral Montana
compared with Montana overall.
Source: Montana Department of Public Health and Human Services
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Cancer incident rates for Region 2 are above Montana overall rates, with prostate, colorectal, and
lung cancer incidences higher than Montana overall. Incidences of breast cancer are slightly lower in
Region 2.
3.4.2 Heart Disease and Stroke
Cardiovascular disease remains the second leading cause of death in Montana; the majority of these
deaths (29%) were due to heart disease and stroke (Montana Heart Disease and Stroke Prevention,
State Plan 2010-2012). Risk factors for the development of heart disease include family history of
premature coronary artery disease, cigarette smoking, high cholesterol, hypertension and diabetes.
Obesity, physical inactivity, and stress are also contributing factors.
Information regarding stroke and heart attack is available for Region 2. Both stroke and heart attack
prevalence are higher in Region 2 than in Montana overall. The following are the reported responses
from the BRFSS survey.
Core Indicator
6. Stroke Prevalence
8. Acute Myocardial Infarction
Prevalence
Region
2.9%
(2.4-3.5)
4.4%
(3.8-5.1)
Montana
2.5%
(2.3-2.8)
4.1%
(3.8-4.4)
Data Source/Definition
Ever diagnosed with a stroke. BRFSS. 2003,
2005-2008 data
Ever diagnosed with a heart attack. BRFSS
2003, 2005-2008 data
Source: Montana Department of Public Health and Human Services
3.4.3 Diabetes
Diabetes is an extremely expensive chronic disease because of its chronic complications such as end
stage renal disease, diabetic blindness, lower extremity amputation, and heart disease. Diabetes is
more prevalent in Region 2 than in Montana overall.
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Core Indicator
7. Diabetes prevalence
Region
7.5%
(6.7-8.3)
Montana
6.2%
(5.9-6.5)
Data Source/Definition
Ever told by a doctor they had diabetes. BRFSS
Source: Montana Department of Public Health and Human Services
3.4.4 Obesity
Over the past twenty years, obesity rates have increased in the United States, doubling for adults and
tripling for children (U.S. Department of Health and Human Services). Overweight and obesity was
the fourth most important health concern indicated by the Hill County survey respondents. Based on
Body Mass Index, 38.3% of Region 2 residents are overweight and 26.3% of residents are obese
which are both higher than Montana overall. See the Body Mass Index chart following the statistics.
Source: Montana Department of Public Health and Human Services
Body Mass Index Chart
Being overweight or obese puts an individual at higher risk for heart disease and diabetes.
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3.5 Mental Health and Mental Disorders
Social and mental health is as important to overall health as is physical health. Below are a number
of important social and medical health indicators for Hill County as compared to Montana overall.
Source: Montana Department of Public Health and Human Services
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The 3-year rate of family offenses in Hill County is over three times that of Montana overall, with the
3-year domestic abuse rate in Hill County double that of Montana overall. The 3-year rate of sex
offenses and rape in Hill County is also higher than Montana overall. The suicide rate is lower in Hill
County than Montana overall.
Hill County survey respondents were asked what they considered to be the most important mental
health issues that impact themselves and their families. They identified work related stress,
depression, and alcohol abuse as the most important. The concern regarding alcohol abuse is much
more prominent for Hill County residents than Montana overall.
Three Most Important Mental Health Issues That Impact You and Your Family
70%
60%
50%
Hill County (n = 50)
40%
30%
NC MT (N = 729)
20%
10%
0%
Work‐related stress
Depression
Alcohol use 3.6 Dental Services
Hill County is a designated dental health professional shortage area by the U.S. Department of Health
and Human Services, Health Resources and Services Administration. Only 52% of the Hill County
Community Health Assessment survey respondents said they had dental insurance. Dental care was
identified as the fifth most serious health concerns by Hill County survey respondents.
3.7 Hospitalizations
Hospital admission information is available through the Montana Hospital Discharge Data Base, a
database to which most acute care hospitals report. It does not include Indian Health Service
admission data. Annualized data for 2012 shows there were 1,916 Hill County residents who were
hospitalized. Hospitals to which patients were admitted are shown below.
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7.35% OTHER
27.04% BENEFIS HEALTH SYSTEM
65.61% NORTHERN MONTANA HOSPITAL
Hospitalization rates for residents of Hill County, as noted below, were quite higher for all core
indicators than Montana overall.
Source: Montana Department of Public Health and Human Services
3.7.1 Public Health Issues: Communicable Diseases
Many diseases transmitted through person-to-person exposure can be prevented through high level
vaccination coverage or use of protective measures. The following information is for Hill County
compared to Montana overall.
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Source: Montana Department of Public Health and Human Services
The proportion of children receiving age-appropriate vaccinations by 24 months is higher in Hill
County than Montana overall, along with adults aged 65 and older who are immunized against
influenza. The Chlamydia rate in Hill County is twice that of Montana overall – 777.9 compared to
321.4. The tuberculosis rate is also much higher in Hill County. Gonorrhea, pertussis, and
salmonellosis rates are lower in Hill County than Montana overall.
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3.8 Access to Care
3.8.1 Medical Manpower Needs
A Health Provider Manpower projection model has been developed by Benefis Health System to help
guide the manpower needs for a given community. The projection model is based on a range of
patient visits per physician specialty (capacity) and a range of patient visit utilization per 1,000
population in a rural setting. The manpower needs are then compared to current providers in a given
community. This model was applied to Hill County with the following results.
TOTAL
Predicted
Need (Hi
Productivity)
Family Practice Internal Medicine7 General Surgery Internal Medicine7 OB/GYN4 Orthopedic Surgery Pediatrics3 Psychiatry TOTAL
Predicted
Need (Lo
Productivity)
2.3 1.9 0.4 1.9 0.7 0.5 1.1 0.5 3.6 3.2 1.0 3.2 1.5 1.0 1.9 1.3 Current
Supply
5.0 4.0 2.0 4.0 1.0 2.0 1.0 1.0 Additional
Physicians
Needed
0.0 0.0 0.0 0.0 0.0 0.0 0.9 0.0 3.8.2 Survey Results
Survey respondents were asked if they were not able to get or were delayed in getting needed health
services in the past three years. The respondents answered that they experienced not getting or had
a delay in getting needed health care services 26% of the time which was lower than North Central
Montana responses overall.
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Did Not Get or Were Delayed Getting Health Services
Hill County
65.6%
62.0%
70%
60%
50%
NC MT (N = 729)
30.7%
26.0%
40%
Hill County (n = 50)
30%
20%
10%
0%
Yes
No
The survey respondents were asked “What were the most important reasons for delay or not getting
needed health care services?” For Hill County the most important reason was “It cost too much.”
Other reasons are shown in the graph below.
What Were The Most Important Reasons for the Delay?
Hill County
8%
Could not get off work
Could not get an appointment
10%
Cost too much
10%
It was too far to go
10%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
3.9 Population Based Health
3.9.1 Child and Maternal Health
The health of women and children will determine the health of the next generation and can help
predict future public health challenges for families, communities and the health care system (U.S.
Department of Health and Human Services, 2010). Some of the important criteria are low birth
weight, infant deaths and teen mothers. Maternal and child health indicators provide information of
the determinants, mechanisms and systems related to the health and well-being of women and
children. The following chart provides information on maternal and child health indicators for Hill
County compared to Montana overall.
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Source: Montana Department of Public Health and Human Services
Mothers receiving prenatal care in the first trimester is significantly lower in Hill County than Montana
overall. Births to adolescents aged 15 to 17 years old is higher in Hill County than Montana overall
along with smoking during pregnancy.
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3.9.2 Native Americans
Montana's 60,000 Native Americans, who comprise 6.2 percent of Montana's population, experience
significant health disparities compared to non-Native Americans. For example Montana Native
Americans are 42 percent more likely to die of cancer, 291 percent more likely to die of diabetes, and
100 percent more likely to experience infant mortality than non-Native American Montanans as shown
in the table below. This data is not current; however, this is the most recent data available. Based on
experience, causes of death most likely have remained the same in the past few years.
Source: Montana Department of Public Health and Human Services
Almost 70% (42,000) of Montana’s Native American population reside in north central Montana. The
primary counties affected by the health disparities of Native Americans are Glacier County (Blackfeet
Reservation), Hill and Chouteau Counties (Rocky Boy Reservation), Blaine County (Fort Belknap
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Reservation), Roosevelt County (Fort Peck Reservation) and Cascade County (urban Native
Americans). Meeting the critical needs of this population should be a health priority.
IV. NEXT STEPS
The next steps following the community health needs assessment report will be to present the
findings of the report to the community. One or more community meeting(s) will be held to present
the data and discuss the health needs of Hill County. During the community meeting(s), a consensus
will be obtained to identify the three highest priority health needs that can be addressed. Following
the community meeting(s) a Community Health Improvement Plan will be developed to help guide
community action to address the three health priority needs through the identification of specific
objectives or actions over the next three years. Specific measures of the three priority needs will be
identified to enable the measurement of impact of community actions on the priority areas.
V. APPENDICES
Appendix A North Central Montana Healthy Communities Collaborative Partners
Appendix B Survey Questionnaire
Appendix C Community Needs Index Details
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